Understand the Fundamentals of Treating Older Patients with Atopic Dermatitis

As our largest organ, the skin deserves the same health care emphasis that we direct at the rest of our body. Atopic dermatitis (AD)—usually presenting as itching, eczema, and dry skin—is an inflammatory skin condition that can greatly affect quality of life. Various environmental and genetic factors contribute to the development of AD.

Expert Review of Clinical Immunology has published a reviewthatsheds light on the importance of diagnosis and difficulty of treating older patients with AD. It is known that aging leads to a decreased function of the skin barrier due to its thinness and fragility.

Image credit: rocketclips | stock.adobe.com

AD can stem from environmental factors such as migration and urbanization. These exposures contribute to the modification of the microbiome, leading to a flare of AD. With age, skin dryness, infections, and pigmentary changes may occur due to a higher susceptibility to bacterial infections and sensitivity to allergens such as pollen and dust mites. All of these environmental factors can lead to epidermal damage.

In addition, anti-inflammatory and inflammatory systems may become unbalanced with aging. Chronic inflammation, or “inflammageing,” may occur due to prolonged exposure and the overproduction of the Th2 inflammatory responses, interleukin (IL)-4 and IL-13. These imbalances reduce the body's response to infections, negatively impacting the body's healthy processes.

Currently, no specific diagnosis criteria for AD in elderly patients exist that consider their various comorbidities (diabetes, heart disease, hypertension, etc.) and medication regimens that lead to xerosis and itching. AD in patients 60 years of age and older is associated with active scalp, facial, and genital lesions. It is less commonly seen in areas like the elbow or knee bends. Clinicians must conduct histopathologic evaluation of older patients’ skin lesions to differentiate the diagnosis from other chronic skin diseases.

Once a patient is diagnosed, determining the proper treatment approach can be complicated with older patients. Although systemic anti-inflammatory medications are indicated for most patients with moderate-to-severe AD, their use in older patients is limited due to comorbidities. Instead, patients 65 years or older should use a topical formulation of corticosteroids in conjunction with topical moisturizers to help alleviate dryness. Patients should also try to avoid allergens and irritants in their environment as much as possible to avoid flare-ups in their skin.

If a topical regimen is insufficient to control AD, patients can try a human monoclonal antibody like dupilumab or tralokinumab. Both medications have been tested in clinical trials on patients over the age of 65 and although limited, the data have shown promising results for older patients with moderate-to-severe AD. Dupilumab focuses on inhibiting IL-4 whereas tralokinumab targets IL-13. These medications are injectable formulations which may require outpatient visits or potentially at-home help. As a last line, if other treatments are not available for patients with elevated risk of cardiovascular diseases or cancer, older patients may consider JAK inhibitors.

When treating AD in older patients, avoid the use of systemic anti-inflammatory medications. Using a topical corticosteroid along with a moisturizer will improve the patient’s skin. Second line options include dupilumab or tralokinumab, whereas JAK inhibitors are considered last line. Treating older patients requires a greater focus on treating their AD without exacerbating their comorbidities.

About the Author

Samantha Gorski is a 2025 PharmD candidate at the University of Connecticut School of Pharmacy in Storrs.

Reference

Napolitano M, Potestio L, Nocerino M, Patruno C. Considerations for managing elderly patients with atopic dermatitis. Expert Rev Clin Immunol. Published online January 9, 2024. doi:10.1080/1744666X.2024.2301967